Form 1 SC Independent Living Impact Evaluation CATI

Study 3 Senior Corps Independent Living Evaluation Survey

OMB Control Number xxxx-xxxx Expires xx/xx/xxxx

DRAFT May 20, 2013

1. Sponsoring Organization

This section will be pre-loaded based on information gathered from the project director or another representative from the sponsoring organization.

_________________________________ _________________

Organization Name Grant Number

2. Name of Client

______________________ ____ ________________________

First Middle Last

3. Salutation used for the client

   1. Ms. or Mrs.

   2. Mr.

4. When did the client begin receiving services from a Senior Companion?

Month___________________ Year_____________

5. Date of the interview

_______________ ______ ____________

Month Day Year

Part 1: First I want to start with questions about you and your Senior Companion services.

6. Are you a Senior Companion Client or a Caregiver of a Senior Companion Client?

   1. Senior Companion Client [START WITH QUESTION 7 AND WORK THROUGH THE ENTIRE SURVEY]

   2. Assisting Client to complete survey where Client provides response [START WITH QUESTION 7 AND WORK THROUGH THE ENTIRE SURVEY]

   3. Proxy for Senior Companion Client by answering the survey on behalf of the Client

IF USING A PROXY:

1. Reasons a proxy is needed (e.g., specify types of impairment): _______

2. Relationship of proxy to client (e.g., spouse, adult child, another relative, family friend, primary caregiver): ____________________

3. Client has given consent for an interview to be conducted with proxy: ________ (yes/no)

IF USING A PROXY: ASK QUESTIONS 9 THROUGH 14, SKIP QUESTIONS 15 THROUGH 22; ASK QUESTIONS 23 THROUGH 37]The next question is about how you feel about different aspects of your life

Life satisfaction

7. Please think about your life-as-a-whole. How satisfied are you with it? Are you satisfied or not satisfied? [Check one box] ⁱ

If satisfied: Are you…

1. Completely satisfied

2. Very satisfied

3. Somewhat satisfied

If not satisfied: Are you…

4. Not very satisfied

5. Not at all satisfied

8. Don’t know

9. Refuse (I prefer not to answer)

Next I have questions about your health.

8. Would you say your health is excellent, very good, good, fair, or poor? [Check one box] ⁱⁱ

1. Excellent

2. Very good

3. Good

4. Fair

5. Poor

8. Don’t know

9. Refuse (I prefer not to answer)

9. Has a medical doctor ever told you that youⁱⁱⁱ...

	1. Yes	2. No	8. Don’t know	9. Refuse
Have high blood pressure or hypertension?
Have diabetes or high blood sugar?
Have cancer or a malignant tumor, excluding minor skin cancer?
Have chronic lung disease such as chronic bronchitis or emphysema?
Had a heart attack, coronary heart disease, angina, congestive heart failure, or other heart problems?
Had a stroke?

10. Have you ever had or has a doctor ever told you that you^iv …

	1. Yes	2. No	8. Don’t know	9. Refuse
Had any emotional, nervous, or psychiatric problems?
Have arthritis, osteoarthritis, or rheumatism?

We would like to understand difficulties people may have with various activities because of an illness or health or physical problem. Please tell me whether you have any difficulty doing each of the everyday activities that I read you.

11. Because of a health problem do you have any difficulty with^v…

	1. Yes	2. No	3. Can’t do	4. Don’t do	8. Don’t Know	9. Refuse
Walking one block?
Getting up from a chair after sitting for long periods?
Reaching or extending your arms above shoulder level

12. Does any impairment or health problem limit the kind or amount of work you can do around the house?^vi

    1. Yes GO TO Q13

    2. No GO TO Q14

    3. Too old to work GO TO Q14

8. Don’t know GO TO Q14

9. Refuse (I prefer not to answer) GO TO Q14

13. Does this limitation keep you from working around the house altogether?^vii

    1. Yes

    2. No

8. Don’t know

9. Refuse (I prefer not to answer)

14. Part of this study is concerned with people's memory, and ability to think about things. First, how would you rate your memory at the present time? Would you say it is excellent, very good, good, fair or poor?^viii

1. Excellent

2. Very good

3. Good

4. Fair

5. Poor

8. Don’t know

9. Refuse (I prefer not to answer)

Now think about the past week and the feelings you have experienced. Please tell me if each of the following was true for you much of the time during the past week.

15. Much of the time during the past week^ix…

	1. Yes	2. No	8. Don’t Know	9. Refuse
a. you felt depressed.
b. you had a lot of energy.

Self-Efficacy

Now please tell me how much you agree or disagree with the following:

16. I can do just about anything I really set my mind to. Do you agree or disagree with this statement?^x

If disagree: Do you

1. Strongly disagree

2. Somewhat disagree or

3. Slightly disagree

If agree: Do you

4. Slightly agree

5. Somewhat agree or

6. Strongly agree

17. I can do the things that I want to do. Do you agree or disagree with this statement?^xi

If disagree: Do you

1. Strongly disagree

2. Somewhat disagree or

3. Slightly disagree

If agree: Do you

4. Slightly agree

5. Somewhat agree or

6. Strongly agree

Social Loneliness

18. How much of the time do you feel that you are alone? Would you say often, some of the time, or hardly ever or never [Check one box] ^xii

1. Often

2. Some of the time

3. Hardly ever or never

8. Don’t know

9. I prefer not to answer

19. How much of the time do you feel that you lack companionship? Would you say often, some of the time, or hardly ever or never [Check one box] ^xiii

1. Often

2. Some of the time

3. Hardly ever or never

8. Don’t know

9. I prefer not to answer

Emotional Loneliness

20. How much of the time do you feel that there are people you feel close to? Would you say often, some of the time, or hardly ever or never [Check one box]^xiv

1. Often

2. Some of the time

3. Hardly ever or never

8. Don’t know

9. I prefer not to answer

21. How much of the time do you feel that there are people you can turn to? Would you say often, some of the time, or hardly ever or never [Check one box] ^xv

1. Often

2. Some of the time

3. Hardly ever or never

8. Don’t know

9. I prefer not to answer

Part 2: Performance Measure

22. Because I Have a Senior Companion Volunteer …

	If Disagree, Do you…		If Agree, Do you…
	1. Strongly Disagree	2. Somewhat Disagree	3. Somewhat Agree	4. Strongly Agree
I feel less lonely. Do you agree or disagree?
I feel I have close ties to more people. Do you agree or disagree?
I am able to do more of the things I need to do. Do you agree or disagree?
I am able to do more things I want to do. Do you agree or disagree?
I am eating regularly scheduled meals. Do you agree or disagree?
I am able to get to medical appointments. Do you agree or disagree?

Part 3: Background questions about the client

I want to ask you a few questions about yourself. Your answers will help us understand the characteristics of the people who participated in this survey.

23. In what month and year were you born?

1. Month

01. JAN

02. FEB

03. MAR

04. APR

05. MAY

06. JUN

07. JUL

08. AUG

09. SEP

10. OCT

11. NOV

12. DEC

98. Don’t Know

99. Refuse

2. Year _______________

9998. Don’t Know

9999. Refuse

24. Do you consider yourself primarily ^xvi

1. White/ Caucasian

2. Black/ African American

3. American Indian or Alaskan Native

4. Asian Native Hawaiian, or Pacific Islander

5. Other

8. Don’t Know

9. I prefer not to answer

25. Do you consider yourself Hispanic or Latino^xvii

1. Yes

2. No

8. Don’t know

9. Refuse (I prefer not to answer)

26. What is your Veteran Status [Check all that apply]

1. I am Active Duty or Reserve Component

2. An immediate family member is Active Duty or Reserve Component

3. I am a Veteran

4. An immediate family member is a Veteran

8. Don’t Know

9. I prefer not to answer

27. What is the highest grade of school or year of college you completed^xviii

1. No formal education

2. Grades 1- 11

3. Grade 12 (High School Diploma or GED)

4. Some College

5. Associate’s Degree

6. Bachelor’s Degree/ College Graduate

7. Some graduate school

8. Completed a graduate/professional degree

9. Other

10. I don’t know

11. Refuse (I prefer not to answer)

28. Are you currently married, have a partner as if married, separated, divorced, widowed, or never married? ^xix

1. Married

2. Have partner

3. Separated

4. Divorced

5. Widowed

6. Never Married

7. Other

8. I prefer not to answer

29. Are you male or female^xx? (Ask only if you do not know from Q3 above; or there is a discrepancy with what is listed as the respondent’s gender.)

1. Female

2. Male

8. Not answered/Don’t Know

9. Refused

Household

30. Do you generally live alone or with others?

1. Alone GO TO Q32

2. With others GO TO Q31

8. Don’t Know GO TO Q32

9. Refuse (I prefer not to answer) GO TO Q32

31. IF LIVING WITH OTHERS: Including yourself, how many people live in your household?

Number ___________________________

31. How many children do you have?

Number of children _____________ GO TO Q33

0. None GO TO Q34

8. Don’t Know GO TO Q34

9. Refuse (I prefer not to answer) GO TO Q34

31. IF HAS CHILDREN: Do any of your children live within 10 miles of you^xxi?

1. Yes

2. No

8. Don’t Know

9. Refuse (I prefer not to answer)

Medicare and Medicaid

The next question is about health insurance. Medicare is a public health insurance program for people 65 or older and for disabled persons. (Medicaid/STATE NAME FOR MEDICAID) is a public health insurance program for people with low incomes.

31. Are you currently covered by Medicare health insurance^xxii?

0. Yes

1. No

8. Don’t Know

9. Refuse (I prefer not to answer)

31. Are you currently covered by (Medicaid/STATE NAME FOR MEDICAID) ^xxiii?

1. Yes

2. No

8. Don’t Know

9. Refuse (I prefer not to answer)

Income

31. Which category best describes your total annual household income?

Is your total annual household income greater than $20,000 or less than that?

1. Less

2. Greater GO TO Q37

8. Don’t Know

9. Refuse (I prefer not to answer)

31. IF MORE THAN $20,000: Would you say it is......

1. Between $20,000 but less than $30,000

2. Between $30,000 but less than $40,000 or

3. more than $50,000

8. Don’t Know

9. Refuse (I prefer not to answer)

HRS References http://hrsonline.isr.umich.edu/index.php?p=concord

i Core, section B, B000 Campbell et al (1976)

ii Core, section C, C001 Standard Survey Question

iii Core, section C, C005, C010, C018, C030, C036, C053, C069, C065, C070

iv Core, Section C, C065, C070

v Core, Section G, G003, G005, G009

vi Core, Section M, M006

vii Core, Section M, M008

viii Core, Section D, D101

ix Core, Section D, D110, D118

x Core, Section LB, Q23

xi Core, Section LB, Q23

xii Core, section LB*, Q20a,i Hughes, M. E., Waite, L. J., Hawkley, L. C., & Cacioppo, J. T. (2004)

xiii Core, Section LB*, Q20a Hughes, M. E., Waite, L. J., Hawkley, L. C., & Cacioppo, J. T. (2004)

xiv Core, Section LB*, Q20i Hughes, M. E., Waite, L. J., Hawkley, L. C., & Cacioppo, J. T. (2004)

xv Core, Section LB*, Q20g

xvi Core Section, Section B MB091M

xvii Core Section, Section B , B028

xviii Core Section, Section B, MB014

xix Core Section, Section B, MB063

xx Core Section, Section A, MA008

xxi Core Section, Section E, E012

xxii Core Section, Section N, N001

xxiii Core Section, Section N, N006

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